Stroke-Induced Central Pain: Overview of the Mechanisms, Management, and Emerging Targets of Central Post-Stroke Pain

Abstract

The incidence of stroke plays the foremost role in the genesis of central neuropathic pain. Central post-stroke pain (CPSP) is a central pain arising from a vascular lesion in the central nervous system that elicits somatosensory deficits, often contralateral to stroke lesions. It is expressed as continuous or intermittent pain accompanied by sensory abnormalities like dysesthesia and allodynia. CPSP remains de-emphasized due to the variation in onset and diversity in symptoms, besides the difficulty of distinguishing it from other post-stroke pains, often referred to as a diagnosis of exclusion. Spinothalamic dysfunction, disinhibition of the medial thalamus, and neuronal hyperexcitability combined with deafferentation in thalamocortical regions are the mechanisms underlying central pain, which play a significant role in the pathogenesis of CPSP. The treatment regimen for CPSP seems to be perplexed in nature; however, based on available studies, amitriptyline and lamotrigine are denoted as first-line medications and non-pharmacological choices may be accounted for cases intractable to pharmacotherapy. This review attempts to provide an overview of the mechanisms, existing management approaches, and emerging targets of CPSP. A profound understanding of CPSP aids in optimizing the quality of life among stroke sufferers and facilitates further research to develop newer therapeutic agents for managing CPSP.

Successful relief of central poststroke pain with BurstDR spinal cord stimulation: A case series

“…CPSP occurs when a stroke results in a lesion of the spinothalamic tract (STT) of the central nervous system. [ 6 ] Tonic SCS treats neuropathic pain by stimulating inhibitory interneurons in the dorsal horn of the spinal cord, decreasing pain by activating the lateral STT. Burst SCS activates the interneurons and supraspinal areas involved in the emotional processing of pain (i.e., through activation of both the medial and lateral STT).…”

“…[ 7 ] It is characterized by pain and altered sensation after a stroke without another discernible cause due to a lesion of the central nervous system. [ 6 ] Spinal cord stimulation (SCS) is a newer neuromodulatory treatment whose efficacy in treating CPSP is not well established. Here, we utilized BurstDR SCS in two patients to better establish the efficacy of SCS in providing pain relief for CPSP patients.…”

Post-stroke pain and rehabilitation (case report)

“…По результатам различных исследований в качестве медикаментозной терапии возможно использование трициклических антидепрессантов (амитриптилин), селективного ингибитора обратного захвата серотонина (флувоксамин), селективных ингибиторов обратного захвата серотонина и норадреналина (венлафаксин, милнаципран и дулоксетин). Однако применение этих препаратов после инсульта у пациентов пожилого возраста требует тщательного контроля [30,31].…”

Repetitive transcranial magnetic stimulation in central post-stroke pain: a meta-analysis and systematic review of randomized controlled trials

“…Currently, the primary approach involves medications for neuropathic pain. Existing evidence suggests that even with the use of high-dose medications, pain relief is often difficult to achieve for the majority of CPSP patients (Scuteri et al, 2020 ; Singh et al, 2020 ; Choi et al, 2021 ; Mohanan et al, 2023 ). Additionally, these medications are associated with various side effects (Banerjee et al, 2013 ; Kim, 2014 ) and may lead to drug dependence (Kumar and Soni, 2009 ).…”

“…In recent years, some reviews have summarized the impact of rTMS on pain (Pan et al, 2022 ; Cheng et al, 2023 ; Mohanan et al, 2023 ; Radiansyah and Hadi, 2023 ), suggesting that rTMS may have a beneficial effect in alleviating pain. However, some reviews primarily focus on exploring the mechanisms and concentrate on conditions such as fibromyalgia, postherpetic neuralgia, malignant neuropathic pain.…”